- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $128.82 / $223.87
| Professional | | $97.72 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $138.04 / $181.97
| Professional | | $102.33 | $138.04 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $165.96 / $229.09
| Professional | | $114.82 | $165.96 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $158.49 / $1,071.52
| Professional | | $117.49 | $158.49 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $123.03 / $173.78
| Professional | | $93.33 | $123.03 | $173.78 |